Bmjopen 2020 044291

Open access Original research
Initiatives for improving delayed

discharge from a hospital setting: a
scoping review
Lauren Cadel ‍ ‍,1,2 Sara J T Guilcher ‍ ‍,2,3,4,5 Kristina Marie Kokorelias,3
Jason Sutherland,6 Jon Glasby,7 Tara Kiran,4,5,8,9 Kerry Kuluski1,4
To cite: Cadel L, Guilcher SJT, ABSTRACT

Kokorelias KM, et al. Initiatives Strengths and limitations of this study
Objective The overarching objective of the scoping review
for improving delayed discharge was to examine peer reviewed and grey literature for best
from a hospital setting: a ►► To our knowledge, this is the first scoping review
practices that have been developed, implemented and/
scoping review. BMJ Open to identify best practices for delayed discharges in-
or evaluated for delayed discharge involving a hospital
2021;11:e044291. doi:10.1136/ volving a hospital setting.
bmjopen-2020-044291 setting. Two specific objectives were to review what the
►► The Preferred Reporting Items for Systematic
delayed discharge initiatives entailed and identify gaps in
►► Prepublication history and
Reviews and Meta-Analyses extension for Scoping
the literature in order to inform future work.
additional material for this paper Reviews Checklist was followed.
Design Scoping review.
is available online. To view these ►► A comprehensive search of peer reviewed and grey
Methods Electronic databases and websites of
files, please visit the journal literature was conducted.
government and healthcare organisations were searched
online (http://dx.doi.org/10. ►► A critical appraisal of the interventions was not
1136/bmjopen-2020-044291). for eligible articles. Articles were required to include an
performed.
initiative that focused on delayed discharge, involve a
Received 31 August 2020 hospital setting and be published between 1 January
Revised 18 January 2021 2004 and 16 August 2019. Data were extracted using
Accepted 25 January 2021 Microsoft Excel. Following extraction, a policy framework home with services).1 While waiting for their
by Doern and Phidd was adapted to organise the included next destination, patients’ level of care and
initiatives into categories: (1) information sharing; (2) tools activation often decrease or stop entirely.
and guidelines; (3) practice changes; (4) infrastructure and Delayed discharge can result in hospital
finance and (5) other. patient flow issues (eg, emergency service
Results Sixty-six articles were included in this review.
backlogs, cancelled surgeries, delays in
The majority of initiatives were categorised as practice
medically necessary care),2 increased health-
change (n=36), followed by information sharing (n=19)
and tools and guidelines (n=19). Numerous initiatives care costs,3 an increased risk of functional
incorporated multiple categories. The majority of initiatives decline,4 5 falls,6 hospital- related adverse
were implemented by multidisciplinary teams and resulted events (eg, medication error, exposure to
in improved outcomes such as reduced length of stay and infectious disease),6 7 mortality,8 as well as
discharge delays. However, the experiences of patients poor patient and family experiences.9
and families were rarely reported. Included initiatives also Patients who experienced a delayed
lacked important contextual information, which is essential discharge in previous studies exhibited
for replicating best practices and scaling up. the following characteristics: female,10
Conclusions This scoping review identified a number of older,10 11 physically or cognitively
initiatives that have been implemented to target delayed
impaired.4 12–15 Patients have also shown to
discharges. While the majority of initiatives resulted
exhibit aggressive behaviours,16 use assistive
in positive outcomes, delayed discharges remain an
international problem. There are significant gaps and devices17 and have psychiatric conditions,10
limitations in evidence and thus, future work is warranted neurological disorders15 and/or multimor-
to develop solutions that have a sustainable impact. bidity.17 In addition to these patient- level
© Author(s) (or their factors, there are a number of system-level
employer(s)) 2021. Re-use
factors that contribute to delayed discharges,
permitted under CC BY-NC. No
commercial re-use. See rights INTRODUCTION including long wait lists for long- term
and permissions. Published by A delayed hospital discharge (known as care facilities,5 17–19 rehabilitation or other
BMJ. alternate level of care (ALC) in Canada and postacute care (eg, home care),11 12 20–23
For numbered affiliations see delayed transfer of care in the UK) occurs the lack of culturally and religiously diverse
end of article. when a patient is medically approved to be long-term care facilities,15 limited or absent
Correspondence to discharged, but remains in hospital for non- hospital services on weekends24 and organ-
Lauren Cadel; medical reasons (eg, waiting for a long-term isational delays (eg, administrative delays,
lauren.cadel@thp.ca care bed to become available or to transfer delayed assessments).24 25 There are also
Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291 1

Open access
different pressures and priorities across sectors, with little supplemental table 1).36 A protocol for this scoping
incentive to work together as a system. For example, while review was developed in consultation with a librarian at
hospitals may be focused on efficiency and throughput, the University of Toronto, with continuous input from
community- based organisations may be focused on members of the research team.
empowerment, longer-term quality of life outcomes and
working at a pace that works for patients and families. Stage 1: identifying the research question
The funding structure of hospitals and healthcare systems The research question developed to lead this scoping
can also have an impact on overall patient flow, including review was: what is known in the literature about initia-
discharge delays. Although there is wide variation in tives (eg, strategies, programmes, interventions) that
funding structures within and across countries, there is have been developed, implemented and/or evaluated for
potential for funding to either incentivise or disincen- delayed discharge involving a hospital setting? The two
tivise timely hospital discharges.26–30 main aims were: (1) to review what delayed discharge
The combination of patient- level and system- level initiatives entail (eg, characteristics, outcomes) and (2)
factors contributing to delayed discharges can also have to identify gaps in the literature in order to inform future
a large financial impact on patients, families, healthcare studies.
providers and the healthcare system.3 A recent system-
atic review reported that delayed discharges cost approx- Stage 2: identifying relevant articles
imately £200–565 ($C320–$C900) per patient, per day.3 The search strategy was developed with a librarian at the
Further, it was estimated that the National Health Service University of Toronto and through consultations with an
(NHS) (England) spends £820 million ($C1.3 billion) advisory group and collaborators who have experience
every year on patients who have a discharge delay.31 Simi- in clinical practice or administration (see online supple-
larly, a recent report from Canada stated that three hospi- mental table 2 for Medline search strategy). Each search
tals located in Ottawa, Ontario, spend approximately strategy was adapted for the specific database using appro-
$C250 000 per day (combined) on patients occupying priate command line syntax and indexing. The following
beds at a level of care they no longer require.32 In addi- are examples of keywords searched using Boolean oper-
tion to large costs for hospitals and healthcare systems, ators, proximity operators, wild cards and truncations:
delayed hospital discharges can result in out-of-pocket ALC, delayed discharge, delayed transfer, bed blocking,
costs for patients and families.33 Increased out-of-pocket strategy, model, intervention, programme, policy.
costs, in addition to the other uncertainties associated Electronic databases were searched for relevant articles.
with a delay, can heighten stress for patients and families, The following electronic databases were searched on 16
contribute to poor experiences and compromise quality August 2019: MEDLINE (Ovid Interface), EMBASE (Ovid
of life.9 Interface), AMED (Ovid Interface), Cumulative Index
Overall, delayed hospital discharges are problematic to Nursing and Allied Health Literature (EBSCO Inter-
internationally, highlighting a need to identify best prac- face) and Cochrane Library. Grey literature was searched
tices and current initiatives that are concentrating on on the following databases and repositories: OpenGrey,
solutions to this complex problem. To date, the majority Health Services Research Projects in Progress, UpToDate,
of published literature on delayed discharge has focused Community Research and Development Information
on risk factors and characteristics of patients who experi- Services and TSpace, as well as on numerous national and
ence delayed discharge. There has been a limited focus international healthcare and government websites. We
on initiatives that address the delayed discharge problem. also reached out to key stakeholders, including members
Therefore, the purpose of this scoping review was to of our advisory group, to send us relevant reports and
examine peer reviewed and grey literature (literature presentations.
published through non-traditional means) for initiatives
that have been developed and/or evaluated for delayed Stage 3: study selection
discharge from a hospital setting, with the goal of iden- For inclusion, articles (peer-reviewed and grey literature)
tifying best practices for reducing delayed discharge. were required to meet the following criteria: (1) focused
A scoping review methodology was appropriate for on delayed discharge, (2) included an initiative to address
addressing this goal, in order to identify the types of avail- delayed discharge, (3) involved a hospital setting, (4)
able evidence on this topic, examine key characteristics published between 1 January 2004 and 16 August 2019
relating to initiatives for delayed discharge and to identity and (5) peer-reviewed or grey literature. We focused our
knowledge gaps.34 inclusion on initiatives involving a hospital setting because
this is where the problem of delayed discharges surfaces.
Articles were excluded if they met any one of the following
METHODS criteria: (1) focused on changing the threshold/timing
This review followed the scoping review methodology of discharge (early discharge), (2) books, book chapters,
outlined by Levac et al,35 as well as the recently developed opinion pieces or editorials, (3) grey literature that did
Preferred Reporting Items for Systematic Reviews and not sufficiently describe the initiative implemented (eg,
Meta-Analyses extension for Scoping Reviews (see online implementation process, location, population, impact);
2 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access
reviewed at the full-text level. Thirty full-text articles were

independently screened by the research team (LC, KK,
SJTG, KMK, JK and MA) to test their interrater agree-
ment. The remaining full-text articles (peer-reviewed and
grey literature) were double screened by four reviewers
(LC, KMK, JK and MA).
Stage 4: charting the data

The data were charted by two reviewers (LC and KMK)
using a data extraction form in Microsoft Excel. The
form was developed and tested by the research team
in a series of team meetings prior to the extraction of
all data. We conducted spot checking of extracted data
from 15% of the included articles to ensure complete-
ness and accuracy of the extracted data. Any questions
that arose during the charting process were discussed
by the team. Charted data contained the following
information: general information, study characteristics,
population characteristics, initiative characteristics,
Figure 1 PRISMA flow diagram of included articles. characteristics of delayed discharge, study outcomes
PRISMA, Preferred Reporting Items for Systematic Reviews and conclusions.
and Meta-Analyses.
Stage 5: collating, summarising and reporting results
Microsoft Excel was used to conduct a descriptive quanti-
(4) protocols, trial papers or chart reviews or (5) confer-
tative analysis of the included articles, as well as facilitate
ence abstracts or articles without an accessible full text.
qualitative thematic analysis. The thematic analysis of the
Articles were excluded for criteria one (changing the
charted data was an inductive and iterative process, in
threshold/timing of discharge) because the rationale for
which the team (LC, SJTG, KMK and KK) met in-person
having an earlier discharge was often focused on other
to discuss high level concepts and identified common
factors such as cost-savings by reducing length of stay,
rather than specifically addressing a delayed discharge. themes across the included articles. When reviewing the
Articles were excluded if they met criteria two (books, extracted data, we found that the strategies appeared to
book chapters, opinion pieces or editorials) to elimi- cluster into core categories, which aligned with a concep-
nate articles with potential personal biases and summa- tual framework developed by Doern and Phidd.39 This
ries of peer-reviewed literature. Grey literature that did framework classifies policy instruments/tools along a
not provide sufficient details on the initiative (such as continuum (from those that are least coercive like infor-
lacking a description of the components of the initiative) mation sharing to those that are more coercive like public
were excluded. Articles published more than 15 years ownership or, in our case, new infrastructure). We deduc-
ago, before 1 January 2004, were excluded to ensure the tively applied Doern and Phidd’s categories to classify our
initiatives included in this scoping review were relevant to findings, with some minor adaptations. The five adapted
more current health service practices. categories were not mutually exclusive and included: (1)
Articles identified from the database searches were information sharing (live information sharing and docu-
imported into EndNote X9, a reference management mented recommendations); (2) tools and guidelines; (3)
software, where they were deduplicated following Bram- practice changes; (4) infrastructure and finance and (5)
er’s method.37 The initial database searches identified other (see table 1 for category descriptions and exam-
22 704 articles, which were reduced to 15 824 following ples). The categories assisted with the organisation and
deduplication (figure 1). The titles and abstracts of the presentation of the data.
articles were reviewed on Covidence, a software platform
for systematic and scoping reviews.38 The research team Stage 6: consultation
(LC, KK, SJTG, KMK and JK) independently screened the The research team presented findings of the scoping
titles and abstracts of 40 articles to test their agreement. review to key stakeholders (eg, hospital staff, patient and
The reviewers had a good per cent agreement (85%), caregiver partners) through the planning process and
so the remaining articles were divided among the team analysis of results. These meetings were used to inform
and screened by single reviewers (LC, KMK and JK). All search terms, gather relevant documents, obtain feedback
disagreements were discussed in-person by the reviewers on the categorisation/organisation of initiatives, as well
until a consensus was reached; minor revisions were made as identify knowledge gaps in order to develop targeted
to the eligibility criteria to ensure clarity and consistency. and actionable recommendations for future practice,
Following title and abstract screening, articles were policy and research.

Open access
Table 1 Categories, descriptions and examples of initiative categorisation

Category name Description Examples
Information Sharing ►► A—information sharing through in-person ►► A—rounding, team meetings, one-on-on
A—live sharing or technology-based communication communication
B—recommended (synchronous communication) ►► B—examples: suggested strategies
initiatives— calls to action ►► B—information sharing through documents (or ‘calls to action’) which ranged from
which share suggestions, recommendations or recommending investments in new long-
for information purposes (motivation) term care beds, increasing funding for
behavioural supports, audits and reports,
encouraging team building
Tools and guidelines ►► Tangible/concrete guides to inform practice ►► Toolkits, guidelines, escalation processes,
►► Implemented tool/guidance document that is frameworks
being used in the healthcare system
Practice changes ►► A change in how care is delivered ►► Nurse-led discharges, roles of providers
and/or composition of team are organised
differently
Infrastructure and finance ►► Tangible structural or financial changes ►► Financial penalties/incentives, building
more hospital, rehabilitation or long-term
care beds
Other initiatives ►► Different initiative that does not fit into any of ►► Statistical models (predictive modelling)
the above categories
Patient and public involvement The initiatives most commonly targeted adults and older
An advisory council (patient and caregiver partners), adults; however, there were some initiatives targeting the
along with providers, managers and organisational paediatric population. Specific characteristics of the study
leaders identified the lack of understanding about population (ie, age, sex, gender, ethnicity/race, income
the state of evidence around best practices for delayed level, education, marital status, household composition,
discharges, which informed the research question for this employment status, comorbidities) were not reported
scoping review. The advisory council was involved with in the majority of articles. Most peer-reviewed articles
planning meetings where they provided feedback on the (n=31) defined a delayed discharge; however, there was
search terms and analysis. Results will be disseminated a wide variety of definitions for these terms (see online
to the advisory council through presentations and a lay supplemental table 3). The most common definition for
summary. delayed discharge was when a patient was identified as
medically ready for discharge, but remained in hospital.
Table 3 describes the initiative characteristics.
RESULTS Based on Doern and Phidd’s adapted framework,39
Study characteristics we categorised the included initiatives as: information
The database search identified 15 824 unique articles that sharing (n=19); tools and guidelines (n=19); practice
were screened for eligibility; following title/abstract and changes (n=36); infrastructure and finance (n=10); or
full-text review, 66 articles were included in this scoping other (n=3), which are described in detail below (see
review, 49 articles from the database searches and 17 figure 2). Numerous articles used a combination of cate-
articles from the grey literature searches (figure 1). The gories in their initiatives (eg, information sharing and
majority of included articles were quantitative studies practice change).
(n=34), with a few qualitative (n=5), mixed methods
(n=6) or other designs (policy analyses, reviews, case Information sharing
studies and presentations; n=21). There was a large The information sharing category included initiatives
variety of study designs, with few randomised trials and that promoted communication, leadership from senior
prospective studies. Most initiatives were evaluated staff and information exchange within or across organi-
(n=42), with different types of evaluations such as process sations.2 40–55 The majority of information sharing initia-
evaluations and outcome evaluations. The UK (n=21), tives included team meetings and huddles to facilitate
USA (n=18) and Canada (n=17) were the most common communication through in-person interactions between
countries where studies were conducted. Based on the staff, and less often between staff and patients/fami-
year of publication, there was a fairly even distribution of lies.40 41 43 44 46 Information sharing was promoted between
peer-reviewed articles across the years of inclusion (from multidisciplinary teams and patients to improve length
2004 to 2019); however, the majority of grey literature was of stay and continuity of care. For example, Adlington et
published in the last 10 years. Table 2 describes the char- al implemented Plan Do Study Act cycles during weekly
acteristics of included articles. quality improvement meetings, in which driver diagrams

Table 2 Characteristics of included articles
Method
Author (year) Country Objective Study design Participants Sample size Key conclusions
Database searches
Adlington UK Reduce length of stay, bed occupancy Quantitative Older adults (65+) on psychiatric NR ►► Daily rounds and management
(2018)40 and delays in discharge and promote Quality Improvement ward focusing on long-stay patients were
care in the appropriate setting among effective in improving length of stay
functional older adults on a psychiatric and bed occupancy
ward ►► Sustained improvements
needed support from the quality
improvement programme and
community team
Ardagh (2011)63 New Zealand Identify 10 common challenges and Qualitative NR NR ►► To improve patient flow
promising initiatives relating to patient NR and emergency department
flow and emergency department overcrowding the following are
overcrowding needed:
a. a comprehensive, systematic
approach
b. changes to resource usage
c. sharing of expertise and
experience
Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Arendts Australia Determine if hospital length of stay for Quantitative ED patients (65+) diagnosed with 3572 ►► Multidisciplinary allied health team
(2013)68 older patients is reduced when an allied Non-randomised one or more of six conditions assessment in the emergency
health intervention is introduced in the prospective pragmatic (cerebrovascular insufficiency; department has no benefit in
emergency department (ED) study fractured neck of femur; cardiac reducing hospital length of stay
failure; myocardial ischaemia;
exacerbation of chronic airways
disease; respiratory tract infection)
Baumann UK Identify the factors causing good Qualitative Health/social services staff 42 ►► Future research needs to explore
(2007)55 discharge practice performance and Descriptive with managerial involvement in the impact of the identified issues
organisation of services discharges on patients, families and staff
Behan (2005)93 UK Explore the experience of service users Qualitative NR NR ►► Fines have resulted in a reduction
across the UK during the first 6 months Explorative of delayed discharges
of the implementation of the Community ►► The act has brought health and
Care (Delayed Discharges) Act social care together
Béland (2006)69 Canada Assess the transformation of the Quantitative Frail elderly 1309 ►► Changing delivery of care for frail
organisation and delivery of health Randomised controlled elderly persons is feasible
and social services with additional trial ►► Integrated care can reduce hospital
interventions for frail elderly people and nursing home use, without
impacting cost
Blecker USA Evaluate the impact of a weekend Quantitative Non-obstetric patients hospitalised 57 163 ►► Increased care on weekends may
(2015)70 hospital intervention on care processes, Interrupted time series contribute to improved hospital
clinical outcomes and length of stay observational study flow, without negatively impacting
clinical outcomes (30-day
readmissions and mortality)
Continued
Open access
5
6
Table 2 Continued
Method
Boutette Canada Serve frail elderly patients at risk of NR Frail older patients who are at risk of NR ►► Key features of the model:
(2018)71 deconditioning and/or disability, caused Review/ description of deconditioning and/or disability proactive, restorative, collaborative
Open access
by prolonged hospitalisation programme and integrated, client-centred and

cost-effective
Bowen (2014)72 UK Demonstrate that nurse-led discharges Quantitative Adult ear, nose, throat patients 265 ►► Improved efficiency around
can improve efficiency on a short Case study having routine, elective, short stay discharge of elective short-stay ear,
stay surgical ward, without impacting surgery nose, throat patients
patients safety ►► 95% of ear, nose, throat patients
(for simple discharge) are
discharged on time
Boyd (2017)41 USA Explore the leadership strategies used Qualitative Hospital administrators 3 ►► Effective leadership from hospital
by hospital business administrators to Multiple case study administrators contributes to
reduce delayed discharges and improve positive outcomes for patients,
profitability staff and the economy
Brankline USA Provide the appropriate level of care Quantitative Medical floors with primarily elderly 25 ►► Improved information exchange
(2009)47 and patient choice when the patient is Pilot study patients who require nursing home between hospitals and nursing
medically ready for transfer placement after discharge homes
Brown (2008)64 USA Determine if the length of patient stay Quantitative Adult, ASA physical status I, II, and 1198 ►► Decreased postanaesthesia care
is reduced in the postanaesthesia care Prospective clinical III patients (18+) requiring general unit length of stay and discharge
unit when nurses use discharge criteria study anaesthesia delays while maintaining patient
status
Burr (2017)56 Canada Develop a framework that would Case study ALC patients 3 hospitals ►► ALC avoidance reduces burden on
support ALC avoidance strategies Case study patients, families and providers
across the Toronto Central Local Health ►► Long-term solutions to improve
Integration Network patient flow and avoid ALC should
be sustainable and align with other
initiatives
Caminiti Italy Evaluate the effectiveness of a strategy Quantitative Hospital units: geriatric, medicine, 3498 ►► Physician direct accountability can
(2013)42 aimed to reduce delayed hospital Cluster, parallel group, long-term care reduce unnecessary and avoidable
discharge randomised trial/quality hospital days, especially when
improvement delays are within staff control
Chidwick Canada Discuss concepts and ideas that led to Mixed methods ALC patients NR ►► Improved patient flow and
(2017)54 lowest ALC days in the province Quality improvement reduced ALC days through
the implementation of a
multidimensional approach
El-Eid (2015)73 Lebanon Assess the effectiveness of the Six Quantitative NR 17 054 ►► Six Sigma can have a positive and
Sigma method in improving discharge Pre and post- sustainable impact on patient flow
processes intervention study and length of stay
►► Discharge delays should be
addressed through principles of
Six Sigma, rather than institution-
specific interventions
Continued

Table 2 Continued
Method
Gaughan England Investigate the reduction in hospital Quantitative Patients waiting for hospital NR ►► Improved coordination between
(2015)101 bed-blocking due to a greater supply of Statistical modelling - discharge health and long-term care is
nursing home beds or reduced costs Empirical analysis essential for addressing delayed
discharges
Graham UK Evaluate the effect of the laparoscopic Quantitative Laparoscopic cholecystectomy and 128 ►► Nurse-led discharge may increase
(2012)74 nurse specialist on patient discharge Retrospective laparoscopic inguinal hernia repair discharge postlaparoscopic surgery
comparison patients without impacting patient care
Gutmanis Canada Outline change strategies and their Mixed methods Individuals with responsive NR ►► Improved coordination and
(2016)65 impact health system transformation Quality improvement behaviours communication across sectors
and those living with responsive ►► Provided healthcare providers with
behaviours and their family members learning opportunities
Henwood UK Examine the partnership between health Case study Inpatients NR ►► Addressing and improving delayed
(2006)48 and social care by exploring issues with Case study discharges requires partnerships
hospital discharges between health and social care and
a whole systems-based approach
Holland USA Report the development and evaluation Quantitative Inpatients NR ►► Discharge delays can be reduced

(2016)57 of a discharge delay tracking and Practice improvement if system and process breakdowns
reporting mechanism project are identified and addressed
Katsaliaki UK Describe a project investigating Quantitative Inpatients NR ►► Simulation is a suitable
(2005)102 potential care pathways for elderly Discrete-event methodology for recording and
people after discharge from hospital simulation, simulation evaluating the new postacute
model packages
Lees-Deutsch UK Identify core characteristics of patient Quantitative Patients discharged from the acute 50 ►► Criteria-led discharge may be
(2019)66 discharge criteria, recorded in clinical Systematic medicine unit and short-stay units suitable for select patients in
management plans or case notes observational improving timeliness of discharge
retrospective review
Levin (2019)94 Scotland Examine the impact of Intermediate Quantitative Patients aged 75+ 107 022 ►► Immediate impact on days
Care and the 72-hour target on delayed Controlled interrupted delayed, but increasing rates days
hospital discharge time series design delayed over time suggests that
Intermediate Care services may
need to be adapted
Lian (2008)58 Singapore Develop methods to reduce the hospital Quantitative Premature infants 78 ►► Discharge planning should begin
length of stay for premature infants by Retrospective review on hospital admission
30%, within 6 months ►► Nurses should coach parents to
prepare them to care for their infant
at home
Maessen Netherlands Assess the effect of enhanced recovery Quantitative Patients undergoing elective 173 ►► Additional recovery statistics
(2008)75 after surgery programme on discharge Retrospective/ colorectal resection should be added as outcomes of
delays prospective study the ERAS programme
Continued
Open access
7
8
Table 2 Continued
Method
Mahant Canada Determine if an audit-and-feedback Quantitative Paediatric inpatient 3194 ►► Reduced inappropriate hospital
(2008)59 intervention reduces delayed discharge Prospective days, without impacting
Open access
in a general paediatric inpatient unit observational study readmission rates

►► Identified processes that impact
inappropriate hospital days
Mahto (2009)76 UK Determine the effect of a diabetes Quantitative Acutely admitted patients with 137 ►► The restructured hospital diabetes
outreach service on delayed discharges Cross-sectional audit diabetes outreach service improved
and avoidable admissions outcomes for inpatients with
diabetes
Maloney USA Develop a web-based software Quantitative Inpatients NR ►► Healthcare information technology
(2007)49 application used to facilitate timely Quality improvement can facilitate bed management
patient discharge pilot project efficiencies
►► Improved coordination and overall
inpatient flow
Manville Canada Determine if providing interdisciplinary Quantitative Elderly ALC patients (70+) 135 ►► Improved health functional
(2014)95 care on a transitional care unit will result Before-and-after outcomes, delivered at a lower cost
in improved clinical outcomes and lower structured retrospective
costs chart audit
Meehan UK Explore patients’ experiences of Qualitative Patients discharged through 30 ►► Patients and caregivers reported
(2018)77 hospital discharge with the discharge to Descriptive discharge to assess positive and negative experiences
assess scheme with the scheme, but it may be
beneficial in improving outcomes
for some patients
Moeller Canada Assess patient and physician-related Mixed methods Patients with community-acquired 31 ►► Patients outcomes can be
(2006)60 barriers to discharging patients who Retrospective pneumonia improved by standardising care
have met objective criteria assessment through a critical pathway
►► Patients with poor functional
capacity (using the Hierarchical
Assessment of Balance and
Mobility) may need additional
services to improve discharge time
after clinical stability
Mur-Veeman The Explain the theory of buffer NR Bed blockers NR ►► To practically apply buffer
(2011)61 Netherlands management and discuss related Review/ theoretical management, current routines,
previous assumptions paper principles and beliefs should
shift to focus on flow between
organisations rather than within one
organisation
Niemeijer Netherlands Reduce the average length of stay to Mixed methods Trauma patients 2006:1114 ►► Lean Six Sigma is effective in
(2010)62 create more admission capacity and Efficiency improvement 2007:1124 reducing length of stay and
reduce costs project (retrospective improving financial efficiency in
and prospective data trauma care
collection)
Continued

Table 2 Continued
Method
78
Panis (2004) Netherlands Reduce inappropriate hospital stay by Quantitative Mothers of newborn patients 2889 days ►► Discharge criteria can reduce
adjusting patient logistics, increasing Retrospective cohort of hospital inappropriate patient stays related
efficiency and providing comfortable study stay of to discharge processes
surroundings gynaecology ►► Shifting maternity care to
and outpatient settings can reduce
obstetrics hospital length of stay
patients
Patel (2019)43 USA Evaluate the impact of team-based Mixed methods Dissatisfied patients with delayed 1584 ►► Multidisciplinary discharge rounds
multidisciplinary rounds on discharge Quality improvement discharge can improve discharge efficiency,
planning and care efficiency initiative length of stay and 30-day
readmissions
Ali Pirani Pakistan Emphasise the role of nurses to NR Those experiencing delayed NR ►► Nurses play a key role in delivering
(2010)44 determine factors leading to a lack of Review/ summary discharge patient-centred care and can
discharge planning improve discharge planning
processes
►► Nurses must have the appropriate
knowledge about discharge
planning and have the ability to
communicate, coordinate and

educate patients
Qin (2017)103 Australia Identify which barriers to discharge Quantitative NR NR ►► Hospital occupancy rates and
influence hospital occupancy when Simulation modelling overcrowding can be improved by
targeted by a hospital-wide policy improving discharge processes
Rae (2007)96 New Zealand Illustrate how the Delayed Discharge Quantitative Acute general medical 20 034 ►► The project altered staff behaviour
Project solved a bed crisis and Continuous quality around patient discharge resulting
controlled expenditure improvement project in a better use of resources
►► The system crashed 2 years post-
implementation
►► There is too much focus on length
of stay and bed allocations leading
to poor decision making
Roberts Australia Undertake a preliminary trial of the Goal Quantitative Inpatients in two units: SRU or BIRU 202 ►► The programme did not reduce
(2013)50 Length of Stay tool at a rehabilitation Prospective study length of stay and was perceived
centre negatively by staff
Sampson UK Describe bed occupancy data in Quantitative Diabetes inpatients 152 080 ►► Diabetes inpatient specialist nurse
(2006)79 people with diabetes before and after Retrospective study reduced excess bed occupancy
the introduction of a diabetes inpatient
specialist nurse service
Shah (2007)97 England Examine the impact of the Community Quantitative Inpatient - specialties of GM and NR ►► More patients were admitted to GM
Care (Delayed Discharge) Act on Retrospective study OAP services services and had a shorter length
bed occupancy and length of stay in of stay than OAP
Geriatric Medicine (GM) and Old Age
Psychiatry (OAP) services
Open access
Continued
9
10
Table 2 Continued
Method
Sobotka USA Describe a hospital-to-home transitional Case study Paediatric inpatient 1 ►► Transitional care programmes
(2017)51 care model Illustrative case design/ can improve care for vulnerable
Open access
review populations by reducing health and

developmental differences
Starr- Canada Minimise the number of post-acute Quantitative ALC patients NR ►► Inter and intra-professional
Hemburrow patients transitioning from hospital Quality improvement collaboration is important to
(2011)80 to long-term care and develop an standardise discharge processes,
integrated plan for appropriate care and build trust and respect and improve
placement coordination of care
Sutherland Canada Describe structural challenges to NR ALC patients NR ►► A collaborative approach
(2013)45 reduce the impact of ALC patients and Discussion and debate combining the three strategies
to propose policy alternatives that could article should be considered to address
reduce occupancy ALC
Taber (2013)81 USA Test a programme to improve length Quantitative Adult kidney transplant recipients 476 ►► Improving medication safety post
of stay, delayed discharges and early Observational study kidney transplant can improve
readmissions for kidney transplant clinical outcomes (acute rejection
recipients and infection rates, readmission
rates)
Udayai (2012)82 India Reduce patient discharge time through Quantitative Cash patients NR ►► Improving discharge time allowed
a Six Sigma project Time motion study for more patients to be managed,
improving revenue
►► Leadership support and employee
participation were essential for
success
Williams Australia Examine the impact of a critical care Quantitative Patients discharged from the ICU 1123 ►► The critical care outreach role did
(2010)52 outreach service on frequency of Prospective cohort not decrease delayed discharges
discharge delay from the intensive care study ►► Reducing delays requires a
unit collaborative approach focusing on
hospital flow, rather than just the
discharge process
Younis (2011)53 UK Compare the effect of an enhanced Quantitative Patients undergoing anterior 120 ►► Pre-operatively integrating stoma
recovery programme with preoperative Prospective study resection with the formation of a management education into an
stoma education on the number of loop ileostomy enhanced recovery programme can
patients with prolonged hospital stay reduce delayed discharges
Grey literature
Anonymous USA Create an expedited discharge fund to N/A Uninsured patients NR ►► Patients can be safely discharged
(2008)99 pay for goods and services inhibiting a News article through support from the discharge
patient’s discharge (medical equipment, fund
medication and transportation)
Anonymous USA Improve patient flow through initiatives N/A NR NR ►► NR
(2010)46 that decrease length of stay and News article
increase capacity
Continued

Table 2 Continued
Method
Calveley UK Create a tier of support to reduce the N/A NR NR ►► Healthcare solutions should be
(2007)83 unnecessary and costly occupation of Review developed in partnership with
hospital beds health and community service
providers
Manzano- UK Analyse the relationship between N/A NR NR ►► Quantitative measures (days
Santaella Payment by Results and the Delayed Policy analysis delayed and costs) conflict with the
(2009)100 Discharges Act social aspects of overall health and
well-being
Krystal (2019)86 Canada NR Mixed methods Medically and socially complex and 100+ ►► Engaging partners early in the
Continuous quality frail elderly conception of the programme was
improvement and critical to its success
evaluation
Walker (2011)2 Canada Develop recommendations of care for N/A NR NR ►► Community supports should be
frail Canadians N/A increased to keep people in their
home as long as possible
►► Programmes and services should

be aimed at restoration and
reactivation
North West Canada Create a fact sheet of the benefits of N/A Seniors waiting for LTC placement NR ►► Staying home provides benefits
Community staying at home and using Wait at N/A for seniors including fewer risks
Care Access Home (enhanced home care services (germs/ viruses) and a familiar
Centre (2011)88 while people wait for long-term care) setting compared with the hospital
Toronto Central Canada NR N/A NR NR ►► This framework can help improve
Community N/A results around ALC avoidance and
Care Access management
Centre (2015)67
Province of Canada Identify priority strategic initiatives and N/A NR NR ►► NR
New Brunswick implement community support orders Annual report
(2017)92 across the province
NHS UK Create a how-to guide explaining N/A NR NR ►► Clinical leadership is essential for
Improvement implementation approaches to reduce Guide implementing these initiatives
(2018)104 length of stay
Starr- Canada Improve patient flow through the Quantitative NR NR ►► Culture change requires support
Hemburrow implementation of change management Quality improvement and attention to be sustained over
(2010)91 initiatives time
LHIN Canada Help support patients in their homes for N/A Patients (specifically high needs NR ►► Home First should be implemented
Collaborative as long as possible by providing them Implementation guide seniors) as a system-wide approach
(2011)87 with community supports and toolkit
Continued
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11
12
Open access
Table 2 Continued
Method
Shah (2011)90 Canada Ensure the appropriate community N/A High need seniors (75+) NR ►► Key success factors included:
resources are in place to support the Implementation guide eliminating long discharge
patient on discharge and toolkit processes, having engaged
leadership, having measurable
targets, monitoring performance
and educating patients and
providers
Central East Canada Understand the impact of delayed N/A ALC patients NR ►► ALC is a complex issue and
LHIN ALC Task discharges in the Central East regions of Report requires coordination across
Group (2008)84 Ontario (reviewing data, reading reports, sectors
initiating a pilot study, developing a ►► Implementation of the
patient flow map) recommendations will help to
reduce ALC days and improve
patient flow
Adams, Care & UK Assist older patients in returning home Case study Older patients 1 ►► Large savings for the health
Repair England from hospital quickly and safely Case study system can be generated with the
(2017)98 implementation of this intervention
Shah (2010)89 Canada Describe the Home First approach, a Quantitative Elderly patients NR ►► Allows patients the opportunity to
philosophy for reducing ALC Quality improvement regain independence and return
home
►► ALC solutions need a collaborative,
cross-sectoral approach
Joint Scotland Identify 10 action items to transform N/A N/A NR ►► There are a number of factors to
Improvement discharge processes Quality improvement/ successfully reduce delays
Team (2013)85 stakeholder
engagement
ALC, alternate level of care; BIRU, brain injury rehabilitation unit; GM, geriatric medicine; ICU, intensive care unit; N/A, not applicable; NR, not reported; OAP, old age psychiatry; SRU, stroke
rehabilitation unit.

Table 3 Initiative characteristics
Initiative Initiative
Author Description/content Target population Setting category* Results
Database Searches
Adlington40 Quality improvement programme Older adults (>65) on Hospital Information ►► Length of stay was reduced from an average
►► Weekly quality improvement meetings with psychiatric ward Mile End Hospital sharing live of 47 days to 30 days
driver diagrams to implement Plan Do Study (Leadenhall Ward), 26 beds ►► Bed occupancy was reduced from 77% to
Act cycles 54%
Ardagh63 10 promising initiatives NR Hospitals Tools and ►► Identified top 10 challenges and 10 promising
►► Special beds, hospital operations planning, guidelines initiatives related to patient flow and
discharge planning, access to imaging, Practice changes emergency department overcrowding
responsive acute secondary services,
pathways for acute patients, acute demand
mitigation, enhanced ED layout, enhanced ED
senior staffing, engagement of staff
Arendts68 Allied health assessment Patients (>65) Hospitals Practice changes ►► No benefit in reducing hospital length of stay
►► A comprehensive assessment of patients diagnosed with Two Australian tertiary
by an allied health team within hours of one or more of hospitals
presentation to the hospital through the six predetermined
emergency department conditions

Baumann55 N/A Health/ social Hospitals (6 sites) Initiatives ►► 6 high-performing hospital sites identified
►► Qualitative study to identify factors associated services staff 4 southern sites, 2 northern described touch issues impacting delayed discharges
with low rates of delayed discharges with managerial sites on all categories (capacity, internal hospital efficiencies and
involvement in interagency efficiencies)
discharges ►► Resources and teams to prevent avoidable
admissions
►► Discharge teams to support nurses'
discharge planning,
►► Systems for monitoring and communicating
patients' progress,
►► Patient choice protocols
►► Ensure availability of responsive
transportation and discharge lounges
Behan93 Community Care (Delayed Discharge) Act 2003 NR 7 areas across the UK Infrastructure and ►► National decrease in delayed discharges
►► Local authorities are financially responsible finance between 2003 and 2004
(payments) to acute hospital when patients
remain in hospital because community care
arrangements have not been made
Béland69 Integrated care Frail elderly Community service centres/ Practice changes ►► Significant (50%) reduction in the number
►► Community-based multidisciplinary teams who organisations of patients in the integrated care group that
provide integrated care and coordinate health became ALC
and social service ►► No significant differences in utilisation or
costs between groups
►► Increased caregiver satisfaction
Continued
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13
14
Table 3 Continued
70
Blecker 7 day hospital initiative Non-obstetric Hospital Practice changes ►► Decreased average length of stay by 13%
Open access
►► Increased hospital services on the weekend hospitalised patients Tisch Hospital, 705 beds ►► Increased proportion of weekend discharges
(eg, diagnostic imaging, weekend discharges, by 12%
physician and care management services) ►► Decreased 30-day readmissions
►► No changes in mortality
Boutette71 Subacute care unit for frail elderly Frail older patients Hospitals Practice changes ►► N/A
►► Subacute care in a restorative environment who are at risk of Ottawa Hospital; Perley and
(integrated care and restoration) deconditioning Rideau Veterans’ Health
associated with a Centre
long hospitalisation
Bowen72 Nurse-led discharge Adult ear, nose, Hospital Practice changes ►► Significant reduction in rate of delayed
►► Allows nurses to facilitate discharge based throat patients having University Hospital of South discharges in both audits
on specific criteria that was developed to routine, elective, Manchester
guide the discharge process (also allows for short-stay surgery
discharge in evenings and on weekends)
Boyd41 Communication and leadership NR Hospitals (2) Information ►► Strategies for improving delayed discharges
►► Efficient communication and leadership from Part of a hospital sharing live and reducing financial burden included
hospital administrators conglomerate in Chicago efficient communication and effective
leadership
Brankline47 Technology-assisted referrals Elderly patients who Academic Medical Centre Information ►► Decreased length of stay and improved
►► The use of technology to improve information require nursing home sharing live timely discharges of patients resulted in cost
exchange and processes, increase data placement after Tools and savings
accuracy and produce documents hospital discharge guidelines ►► Increased communication within and between
the hospital and nursing homes
Brown64 Discharge criteria Adult, ASA physical Hospital Tools and ►► Decreased length of stay in the post-
►► Nurse implementation of predetermined status I, II, and III Postoperative recovery area guidelines anaesthesia care unit by 24%
discharge criteria (activity, respirations, pulse, patients, 18 years of a large, tertiary-care, Practice changes ►► Reduced discharge delays with nurse-led
blood pressure, pain, etc) or older, requiring academic hospital discharge
general anaesthesia ►► No change in adverse events (airway
obstruction, reintubation, arrest)
Burr56 ALC avoidance framework ALC patients Hospitals (3) Tools and ►► (1) MGH—exceeded ALC target by 20%,
►► A framework of strategies to reduce ALC 1. Michael Garron Hospital guidelines reduced number of ALC patients waiting for
numbers and promote ALC avoidance 2. Humber River Hospital long-term care
3. Toronto General Hospital ►► (2) HRH—culture shift after implementation of
ALC framework recommendations
►► (3) TGH—improved number of ALC admission
avoidance cases
Caminiti42 Physician accountability Hospital Units: Hospital Information ►► Reduction in unnecessary, avoidable hospital
►► Physician motivation and accountability geriatric, medicine, University Hospital of Parma, sharing live days
through monthly reports and audits (can long-term care 1267 beds ►► No significant changes in 30-day readmission
compare their length of stay results to other or mortality
staff)
Continued

Table 3 Continued
54
Chidwick Change ideas ALC patients Hospital Practice changes ►► Lowest ALC days in Ontario
►► Identification of change concepts, followed William Osler Health System Tools and ►► Eliminated ethical errors, improved patient
by the development and implementation of guidelines discharge experience and decreased patient
change ideas to promote behaviour change Information confusion
sharing live
El-Eid73 Hospital throughput project using Six Sigma NR Hospital (tertiary care Practice changes ►► Significant reduction in length of stay
Methodology teaching hospital) post-intervention
►► The use of Six Sigma Methodology to American University of Beirut ►► Decreased discharge time (2.2 hours to 1.7
implement electronic patient requests, a floor Medical Centre, 386 beds hours)
clerk and a billing officer
Gaughan101 Increasing supply of nursing home beds Patients waiting for Hospital Other initiative ►► Increasing home care beds by 10% would
►► The use of modelling to explore the effect of hospital discharge decrease social care delayed discharges by
increased supply of nursing home beds or 6%–9%
lower prices of nursing home beds on bed
blocking
Graham74 Nurse-led discharge Patients receiving Hospital Practice changes ►► Nurse-led discharge group were significantly

►► Nurse-led discharge following list of criteria laparoscopic Leicester Royal Infirmary more likely to be discharged on the day of
(that each patient must meet) cholecystectomy and surgery
laparoscopic inguinal ►► No significant difference in readmission
hernia repair rates or patients seeking primary care
postdischarge
Gutmanis65 Behavioural Supports Ontario Individuals with South West LHIN Practice changes ►► Decreased ALC care cases among persons
►► A quality improvement initiative for older responsive Tools and with behavioural needs
adults with responsive behaviours through behaviours guidelines ►► Improved perceptions from families and
the identification of change strategies and clients around patient care
knowledge translation best practices
Henwood48 Change Agent Team Inpatients Information ►► The Change Agent Team helped support
►► A team partnership between health and social sharing live implementation of contingency arrangements
care to explore the issues around delayed Tools and at the local level
discharges guidelines
Holland57 Tracking and reporting system Inpatients Hospital (academic medical Tools and ►► Individual patient discharges may be
►► Development and evaluation of a discharge centre) guidelines improved by tracking factors that cause
delay tracking and reporting mechanism delays
►► Nurses took the time to provide comments
regarding patient delays
Katsaliaki102 Intermediate care services Inpatients Hampshire Social Services Other initiative ►► 500 new places will help to balance the
►► Statistical simulations to investigate potential demand and capacity for intermediate care
care pathways and associated costs services by avoiding a deterioration of delay
times
Continued
Open access
15
16
Table 3 Continued
66
Lees-Deutsch Criteria led discharge - Selection of Patients for Patients discharged Hospital (acute medicine Tools and ►► 27 patients were suitable for criteria led
Open access
Efficient and Effective Discharge from the AMU and service with four clinical guidelines discharge, 23 were not
►► Patient discharge is guided by a set of clinical both short-stay wards areas) Practice changes ►► Mean wait time for the 27 suitable patients
criteria; once the patient meets the criteria, a prior to discharge was 4 hours and 51 min
member of the team can facilitate discharge ►► Discharge delays were often caused by
system delays
Levin94 Step-up intermediate care units Aged 75+ Hospital Infrastructure and ►► Reduced bed days delayed
►► A bridging service between hospital and home finance ►► Rate of days delayed increased over time
for individuals ready for discharge from acute
care; allows for recovery and regaining of
independence
Lian58 New discharge guidelines for premature babies Premature infants Hospital Tools and ►► Reduced median duration of hospitalisation
►► Development of new discharge guidelines for Singapore General Hospital guidelines from 58.2 days to 34.9 days
premature neonates ►► Cost savings of $6174/infant
Maessen75 Enhanced recovery after surgery Patients undergoing Hospital Practice changes ►► No significant difference in proportion of
►► Reduction in the postoperative recovery period elective colorectal patients with a discharge delay post-ERAS
to reduce overall hospital length of stay resection programme
►► Approximately 90% of patients pre and
post-ERAS were not discharged on the day
discharge criteria/ functional recovery were
met
Mahant (2008)59 Medical Care Appropriateness Protoco-audit and Paediatric inpatients Hospital Tools and ►► Significantly lower risk of inappropriate
feedback Hospital for Sick Children guidelines hospital days
►► A tool that provides information on hospital ►► During the intervention, 33% of bed days
bed use (qualified and nonqualified hospital were nonqualified, compared with 47% pre-
days) intervention
►► No change in 48-hour readmission rate
Mahto 76 Hospital diabetes outreach service Acutely admitted Hospital Practice changes ►► Reduction in bed occupancy, inappropriate
►► A service to prevent admission through a patients with diabetes New Cross Hospital, 700 admissions, delayed discharges and effective
number of strategies (improved access to beds discharge planning
services, management of medical problems,
early discharge planning, organisation of
follow-up care)
Maloney49 Patient tracker Inpatients Hospital Tools and ►► Decreased number of cancelled surgeries,
►► A web-based application to facilitate Primary Children’s Medical guidelines median emergency department length of stay
the discharge process by enhancing Centre Information and average number of inpatient admissions
communication between disciplines sharing live
Manville95 Transitional care unit Elderly ALC patients Hospital Infrastructure and ►► Improved health outcomes and discharge
►► A rehabilitation-style unit with enhanced (70+) St Joseph’s Hospital, 22-bed finance disposition, decreased length of stay and
nursing and rehabilitation services for elderly transitional care unit costs per patient
patients
Continued

Table 3 Continued
Meehan77 Discharge to Assess Patients discharged Hospital Practice changes ►► Assists with early and effective hospital
through D2A discharge
►► Patients who require care support are ►► 60% of patients and caregivers reported a
discharged home, or to the community, positive experience with D2A
for a needs assessment in their personal ►► Communication was noted as an issue
environment
Moeller 60 Critical pathway Patients with Hospital Tools and ►► 58% of patients with a prolonged length of
►► Criteria for the management and discharge of community-acquired Queen Elizabeth II Health guidelines stay felt they were ready to go home once
patients admitted with community-acquired pneumonia Sciences Centre, 637 beds reaching clinical stability, compared with 92%
pneumonia of patients without a prolonged length of stay
►► Hierarchical Assessment of Balance and
Mobility score at clinical stability was
significantly associated with physicians’
and families’ assessment of the patients’
discharge readiness
Mur-Veeman61 Buffer management Bed blockers Hospital to nursing Tools and ►► The lack of cooperation is an inhibitor of
►► A tool that aims to balance patient flow home (intermediate care guidelines buffer management
between hospital and nursing homes by department) ►► Efforts should focus on improving

maximising patient throughput cooperation between providers
Niemeijer62 Lean Six Sigma Trauma patients Hospital Tools and ►► Average length of stay of all patients
►► An initiative based on Lean Six Sigma to University Medical Centre guidelines (surgical and trauma) decreased by 2.9 days
reduce length of stay, improve discharge Groningen, 1339 beds post-intervention
procedures, create admission capacity and ►► Average length of stay of trauma patients
reduce costs decreased by 3.3 days
Panis78 Dutch evaluation protocol Mothers of newborn Hospital Practice changes ►► Reduction in inappropriate patient stay by
►► Altering discharge procedures to assess patients Maternity unit of 17 beds 6.1%
inappropriate hospital stay, efficiency and (715 total hospital beds) ►► Decrease in length of stay by 0.7 days
patient logistics
Patel43 Multidisciplinary team-based structure for Dissatisfied patients Hospital Information ►► Higher proportion of patients discharged
discharge rounds with delayed University of Colorado sharing live before noon, lower length of stay and 30-day
►► Interventions based around multidisciplinary discharge Hospital, 673 beds readmission rate in pilot team compared with
team-based discharge planning rounds control
(afternoon huddles, pilot teams for physician
continuity)
Pirani44 Nurse participation and patient and family Those experiencing NR Information ►► Enhancing nurse involvement in the discharge
involvement delayed discharge sharing live planning process can improve delayed
►► Communication between the nurse and discharges
patient/ family to promote continuity of care
and coordination of services
Qin103 Simulation modelling Varies based on Hospital Other initiative ►► Hospital occupancy can be significantly
►► Statistical simulations to explore patient flow model Flinders Medical Centre reduced, with a reduction from 281.5 to
and different discharge strategies that could (FMC) 22.8 days in the best scenario (instantaneous
reduce hospital occupancy discharge for 24 hours)
Continued
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17
18
Table 3 Continued
96
Rae Delayed discharge project Acute general Hospital Infrastructure and ►► Mean length of stay decreased by 2.6 days
Open access
►► Local authorities are financially responsible medical patients Dunedin hospital finance (from 6.5 to 3.9 days)
(payments) to acute hospital when patients ►► Decreased costs of service delivery by
remain in hospital because community care $2.4 million
arrangements have not been made ►► Bed numbers decreased by 24 (from 56 to
32)
►► No change in readmission rates
Roberts50 Royal Rehabilitation Centre, Sydney, goal length Inpatients in two Hospital Tools and ►► Total discharge delays from the 2 units
of stay tool units: SRU (stroke Hampstead Rehabilitation guidelines totaled 6311 days
►► A tool that reports the length of stay rehabilitation unit) or Centre, 128 beds Information ►► Length of stay was not decreased
benchmark figures on an individual patient BIRU (Brain Injury sharing live ►► Negative perceptions of the programme from
basis Rehabilitation Unit staff
Sampson79 Diabetes inpatient specialist nurse Diabetes inpatients Hospital Practice changes ►► Decreased mean excess bed days by
►► Diabetes management, based on structured Norfolk and Norwich 0.7 days (from 1.9 to 1.2)
group education, for all diabetes inpatients University Hospital NHS
Trust, 989 beds
Shah97 Community Care (Delayed Discharge) Act 2003 Inpatient - specialties Hospitals Infrastructure and GM:
►► Local authorities are financially responsible of Geriatric Medicine finance ►► Decreased median and mean length of stay
(payments) to acute hospital when patients (GM) and Old Age ►► Increased number of finished episodes
remain in hospital because community care Psychiatry (OAP) (inpatient discharges)
arrangements have not been made services ►► No relationship with number of bed days
OAP:
►► Increased median and mean length of stay
►► Decreased number of finished episodes
(inpatient discharges)
►► Increased number of bed days
Sobotka51 Hospital-to-home transitional care programme at Paediatric inpatient Transitional and Respite Practice changes ►► 2 months following support at AHK, the
AHK Centre Information patient transitioned home to be cared for by
Almost Home Kids sharing live his mother and home care team
►► A programme to support and educate families
on providing care for medically stable children
at home
Starr- Home First ALC patients Hospitals Practice changes ►► Rate of ALC patients decreased by at least
Hemburrow80 ►► A programme designed to help keep patients 50% across the region of study
in their homes (with community supports) for
as long as possible; focusing on providing
access to needed services
Sutherland45 Build more; Integrated care; and Financial ALC patients Hospitals Information ►► N/A
incentives sharing
►► Three strategies to improve ALC impact on recommendation
hospitals (build more beds, integrated care, document
financial incentives for post-acute providers)
Continued

Table 3 Continued
81
Taber Comprehensive interdisciplinary improvement Adult kidney Hospital Practice changes ►► Delayed discharges decreased by 14%
initiative transplant recipients Medical University of South ►► Readmission rate (7 day) decreased by 50%
►► A programme implemented by a Carolina ►► Acute rejection and infection rates decreased
multidisciplinary team to improve length
of stay, delayed discharges and early
readmissions through key initiatives
Udayai82 Improvement in discharge process - Six Sigma NR Hospital Practice changes ►► Discharge time was decreased by 21% (from
►► The implementation of strategies using Six 247 to 195 min)
Sigma to improve discharge processes (billing ►► Patients had improved satisfaction with the
hour, patient audits, office executive, priority discharge process
for discharge, ward boys, discharge process
flow)
Williams52 Critical care outreach role Patients discharged Hospital Practice changes ►► Delayed discharges increased by 4% (from
►► The implementation of a critical care outreach from the ICU Royal Perth Hospital, 22-bed Information 27% to 31%)
role to facilitate communication between ICU ICU (570 total beds) sharing live

and ward staff
Younis53 Enhanced recovery programme Patients undergoing Hospital Practice change ►► Average length of stay decreased by 6 days
►► A programme post-colorectal surgery to anterior resection Single district general Information ►► Significant decrease in percent of patients
improve stoma management and expedite with the formation of hospital sharing live experiencing delayed discharge due to
discharge time a loop ileostomy independent stoma management
Grey literature
Anonymous99 Expedited discharge fund Uninsured patients Hospital Infrastructure and ►► A patient from a rural area was provided with
►► A hospital fund to pay for services that are Iowa City, University of Iowa finance $40/week for medications and gas to travel
holding up a patient’s discharge (medical Hospital, 700 beds to a hospital that provided specialised wound
equipment, pharmaceuticals, physical and care
occupational therapy, transportation, etc.) ►► A social worker found a group home for
people with a mental health diagnosis for a
patient who had no social support or funding
Anonymous46 Meetings NR Hospital Information ►► Decreased average length of stay by
►► Daily and weekly meetings to discuss issues University of Cincinnati sharing live 5.34 hours
with patient throughput and strategies for Health University Hospital, ►► Increased accuracy of predicting next day
eliminating barriers 693 beds discharges from the medical/surgical units
by 40%
Calveley83 Tiered community-based services NR Hospital Practice changes ►► NR
►► Three tiers of services to allow for people to Four Seasons Healthcare,
be cared for in their own homes or residential 18 000 beds
units, instead of in hospital
Continued
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19
20
Table 3 Continued
Open access
Manzano- Payment by Results and Delayed Discharges Act NR NR Infrastructure and ►► Payment by Results and the Delayed
Santaella100 ►► Payment by Results pays providers a fixed finance Discharges Act are related policies
price for each individual case, while with the
Delayed Discharges Act, local authorities are
financially responsible when patients remain
in hospital because community care has not
been arranged
Krystal86 Southlake@Home Medically and socially Hospital Practice changes ►► Reduction in ALC days (average of 10.6 days)
►► A team designed to meet the patients care complex and frail Southlake Regional Health ►► 1088 ALC days avoided
needs through partnerships with community elderly Centre ►► Positive patient and provider experiences
and primary care (integrates primary care,
hospital care and home and community care
to develop a personalised care plan)
Walker2 Recommendations for improving care for the NR NR Information ►► NR
ageing population sharing
►► Numerous recommendations to improve recommendation
ALC in acute and community care ranging document
from proactively identifying patients at risk of
decline in primary care to making hospitals
more ‘senior friendly.’
North West Wait at home Seniors waiting for NR Practice changes ►► NR
Community Care ►► Allows seniors to get their healthcare needs LTC placement
Access Centre88 from their home through a variety of services
for a up to 90 days
Toronto Central ALC avoidance framework NR NR Tools and ►► NR
Community Care ►► To create a standardised approach to avoid guidelines
Access Centre67 delayed discharges through 12 leadings
practices and associated strategies (identifying
a date of discharge, engaging with substitute
decision makers, etc)
Province of New ALC collaborative committee NR NR Information ►► Reduction in percentage of acute hospital
Brunswick92 ►► A committee developed to identify and sharing live days used by patients waiting for discharge
implement priority strategic initiatives Practice changes from 19.6% to 17.5%
Infrastructure and
finance
Continued

Table 3 Continued
NHS SAFER patient flow bundle NR NR Information ►► Most effective when used with Red2Green
Improvement104 ►► A tool to reduce delays for patients on sharing days
inpatient wards recommendation ►► Supports decision making by allowing staff to
document visualise plans
Red2Green days NR NR ►► A board (electronic or white) should act as a
►► A tool to reduce unnecessary waiting by focal point for rounds
patients
Long-stay patient reviews NR NR ►► Weekly long-stay patient reviews can reduce
►► Weekly reviews of long-stay patients the number of inpatients with a length of stay
(>20 days), to help address obstacles that are >20 days by up to 50%
delaying discharge
Multiagency Discharge Event NR NR ►► Greatest impact on patients with a length of
►► Review of individual patient journeys by stay >6 days
bringing together senior staff from health and
social care
Central East Home First NR Hospital Practice changes ►► Percent of ALC (acute) reduced from 22%–

LHIN ALC Task ►► A programme designed to help keep patients Halton Health Services, 459 28% to 4%–6%
Group84 in their homes (with community supports) for beds
as long as possible by connecting patients to
their needed resources
Adams, Care Home First Patients (specifically NR Practice changes ►► NR
and Repair ►► A programme designed to help keep high high needs seniors)
England98 needs seniors in their homes (with community
supports) for as long as possible and involve
the family in care
Shah89 Home First High need seniors Trillium Health Partners, Practice changes ►► 2-fold reduction in monthly average of ALC
►► A programme designed to help keep patients (75+) various community and long- patients
in their homes (with enhanced home care term care organisations ►► 30.5% reduction in number of ALC to LTC
supports) as they wait for long-term care hospital referrals
Joint ►► NR ALC patients 9 community hospital Practice changes ►► Expected to reduced ALC days by 30% over
Improvement corporations, 14 hospital the next 3 years
Team85 sites and a mental health
centre in one Ontario region
1642 beds across the
facilities
Adams, Care West of England care and repair Older patients West of England Care and Infrastructure and ►► Substantial cost savings in hospital bed days,
and Repair ►► Enables older patients to return home from Repair finance housing interventions and hospital staff time
England98 hospital quickly and safely by organising and
repairing home (cleaning, clearing clutter, small
adaptations)
Continued
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21
Open access
intermediate care services, adopting a home
Hospital; ICU, intensive care unit; LHIN, local health integration network; LTC, long-term care; MGH, Michael Garron Hospital; N/A, not available; NR, not reported; OAP, old age psychiatry; TGH, Toronto
using a framework for admissions, transfers
►► The equivalent of 35 acute care beds have
screening for frailty, using transitional and

and discharges, appointing a provider for
coordinating the patients discharge plan,
►► 250 people have been diverted from LTC
identifying estimated date of discharge,
AHK, almost home kids; ALC, alternate level of care; D2A, discharge to assess; ED, emergency department; ERAS, enhanced recovery after surgery; GM, geriatric medicine; HRH, Humber River
►► Factors in reducing delays include:
been saved over 2 years
first culture
placement
Results
Practice changes
Practice changes
category*
Initiative
Figure 2 Categories of initiatives for improving delayed

hospital discharges.
Health Integration Network
Mississauga Halton Local
(visual displays) were used to share information with the

Hospital/ community in
multidisciplinary project team on issues affecting length

of stay and hospital bed occupancy.40 This information
was used to guide practice changes aimed at improving
communication during the discharge process (daily
rounds, focusing on long-stay patients), bed management
Setting
(nursing support to prevent deterioration) and commu-

NR
nity services (email updates and involvement of care

coordinators). The majority of initiatives shared informa-
Target population
tion though in- person communication; however, some

*Initiative category is based on Doern and Phidd’s adapted framework Hosseus and Pal.39
Elderly patients
used technology. Caminiti et al used technology-assisted

communication to develop reports and audits to moti-
vate and hold physicians accountable,42 as in some health
systems, physicians play a key role in designating patients
NR
as having a delayed discharge. Profiles for each physician

were created monthly using hospital administrative data
►► Actions to improve the pathway from hospital
►► A programme designed to help keep patients
Home First – 10 actions to transform discharge
(containing length of stay, number of patients discharged

to home focusing on achieving safe, timely
in their homes (with community supports)
that month). All information sharing initiatives resulted

in positive outcomes (eg, reduced length of stay and a
decrease in delayed discharges).
Tools and guidelines

and person-centred care
The tools and guidelines category included initiatives

with actionable, concrete steps or processes in the form of
Description/content
tools, guidelines and models to inform practice.47–50 54–67

Physicians and multidisciplinary teams (eg, nurses, social
workers, discharge planners) frequently implemented
Home First
tool and guideline initiatives. A promising initiative

Initiative
within this category included the ALC Avoidance Frame-

Continued
work, developed by Burr and colleagues, with the goal

of preventing ALC designations and reducing ALC
General Hospital.
rates.56 67 This framework contains 12 leading practices,

Improvement
with specific strategies for organisational assessment.

Table 3
Some of the leading practices include: providing patients

Author
Team85
89
Shah
Joint
and substitute decision makers with an estimated date

of discharge, identifying high-risk patients of becoming

Open access
ALC and implementing escalation processes for the weekend discharges and no impact on readmission rates
management of ALC challenges. Additional initiatives or mortality.
focused on improving patient flow through criteria-led The majority of initiatives categorised as a practice
discharges (discharging patients once a predetermined change resulted in positive outcomes on length of stay and
set of criteria had been met) and critical pathways/ rate of discharge delays. However, there were several initia-
discharge guidelines. tives that were perceived negatively by patients,77 or had
The majority of initiatives categorised as tools and no change68 75 or a negative impact52 on study outcomes
guidelines had positive results,47–49 54–60 62 64–66 which (increase in delayed discharges). Meehan et al explored
included a reduction in hospital days and length of stay. patient experiences with a programme (Discharge to
However, one initiative, the Goal Length of Stay Tool, did Assess) that discharged patients who were clinically ready
not have positive outcomes on length of stay.50 This initia- but still required support, in order for their needs to be
tive incorporated information sharing into a computer- assessed in their own environment (ie, at home).77 Nega-
based programme to identify patients whose length of tive experiences were described by participants (patients
stay exceeded their benchmark figure. It had no change and caregivers) who indicated feeling ignored, had poor
on length of stay and was perceived negatively by staff communication with their healthcare providers and were
because they did not believe the benchmark figure was an not involved in the decision-making process. Negative
accurate representation of a patient’s current functional outcomes were also identified in Williams et al prospective
status and readiness for discharge. cohort study.52 This study evaluated the impact of a crit-
ical care outreach role on delays in discharge and iden-
tified that discharge delays from the intensive care unit
Practice changes
increased over the study period with the implementation
This category included initiatives that altered how usual
of this role. The authors emphasised the importance of
care was delivered.51–55 63–66 68–92 Common practice change
a multifaceted and collaborative approach (involving
initiatives included hospital-based, nurse-led discharges
multiple stakeholders/ team members), focusing on
and cross-sectoral transitional programmes (eg, Home
patient flow throughout the hospital in order to address
First, Discharge to Assess, Hospital to Home). Most were
the numerous factors impacting delays.
implemented by nurses and multidisciplinary teams.
Nurse- led and criteria-
led discharges often involved a
Infrastructure and finance
predetermined list of criteria (clinical parameters) that
The infrastructure and finance category included initia-
a patient was required to meet in order to be discharged
tives that involved tangible structural or financial changes
from hospital by a member of the discharge team. For
(eg, building more long-term care beds to facilitate the
example, Graham et al conducted a retrospective study transition of patients out of hospital, financial penalties
(N=128) to compare nurse-led and doctor-led discharge for remaining in hospital after being medically ready
(standard discharge pathway) postlaparoscopic surgery.74 for discharge).55 92–100 The Community Care (Delayed
For nurse-led discharge, the patient had to meet 13 pre- Discharges) Act in the UK was an initiative identified in
established criteria (stable vital signs and comparable multiple articles.93 96 97 100 This initiative required local
to baseline on admission; achieved optimal mobility; authorities to make payments to acute hospitals when
minimal nausea, vomiting and dizziness; adequate patients could not be discharged because appropriate
pain control; received written and verbal instructions community care arrangements had not been made.
about postoperative care, etc). When compared with Although this measure was not necessarily enforced, it
the doctor-led discharge group (n=64), patients in the created incentive for the hospital and community to work
nurse-led group (n=64) were significantly more likely to together more collaboratively. Additionally, transitional
be discharged on the day of surgery. Incomparing reasons care units94 95 and discharge funds98 99 were common
for the success of the nurse-led model, the authors did initiatives implemented to address delayed discharges
not tieit to patient factors but rather the ready availability among elderly patients. Transitional care units focused
of the nurse specialistwho was able to implement the on rehabilitation to promote recovery and the regaining
clearly outlined discharge criteria (specific fornurse-led of independence, while discharge funds paid for services
discharge) much more quickly than the doctor-led group that were preventing the patient from being discharged
(who did not use suchcriteria). or returning home (eg, medical equipment, medications,
Another unique example of a practice change initiative transportation, home repairs). All initiatives categorised
was the 7-day Hospital Initiative implemented by Blecker as infrastructure and finance had positive results on study
et al.70 The purpose of this observational study was to eval- outcomes, including reductions in discharge delays,
uate the impact of increasing weekend staff (hospitalists, length of stay and cost.93–98
care managers, social workers) and services on length
of stay, percent of patients discharged on weekends, Other initiatives
30-day readmission rate and in-hospital mortality rate. The other initiatives category included statistical and
This multifaceted intervention resulted in a decreased predictive modelling of initiatives to improve delayed
average length of stay, an increased proportion of discharges.101–103 These models explored the impact of

Open access
increasing the supply of nursing home beds,101 potential focused on quantitative outcomes, with limited assess-
care pathways for the elderly and reimbursement costs102 ment of the impact on patient, caregiver and provider
and discharge strategies to reduce hospital occupancy.103 experiences; (2) the sustainability of initiatives overtime
Gaughan et al's modelling and empirical analysis iden- is not measured (3) there is a lack of important contex-
tified that increasing the supply of long-term care beds tual information reported (eg, population characteris-
can decrease delayed discharges caused by a lack of social tics, setting, implementation processes) and (4) there are
care.101 Their models further emphasised the importance inconsistencies in how delayed discharges are defined.
of communication between hospitals and the long-term This review highlighted where the majority of efforts
care sector to reduce social care delayed discharges. Simi- around addressing delayed discharges have been placed.
larly, Katsaliaki et al used discrete-event simulations to Practice change was the most common categorisation of
determine care pathways and associated costs, in which initiatives (n=36), followed by information sharing (n=19)
they identified that adding new beds in hospital or inter- and infrastructure and finance (n=19). All initiatives cate-
mediate care could reduce delay times.102 gorised as information sharing and infrastructure and
finance reported positive outcomes. Despite reporting
Recommended initiatives: calls to action positive outcomes, many information sharing initiatives
Several articles were not evaluations but reports or reviews promoted communication between staff, with a limited
consisting of recommended initiatives to address delayed number targeting communication with patients and
hospital discharges, which often combined a number of families. Additionally, there were more initiatives imple-
the categories illustrated above.2 45 92 104 Sutherland and mented in a single sector (eg, in hospital) in comparison
Crump outlined three key solutions for improving delayed to cross-sectoral initiatives (eg, hospital and home care).
discharges in Canada: building more acute and postacute Length of stay was the most common outcome measured
care beds, increasing integrated care and creating finan- in this scoping review, with a limited number of articles
cial incentives to improve the quality, quantity and effec- exploring patient, caregiver and provider experiences.
tiveness of healthcare.45 The authors discussed challenges For example, could it be considered a success if an initia-
and limitations to implementing each of these options tive does not result in a reduced length of stay, but allows
and emphasised that a potential solution to addressing patients to obtain broader goals related to their care (ie,
delayed discharges was to combine the three strategies. being able to return home) or enhance their care expe-
Another Canadian report developed recommendations rience? Qualitative methods, including the capturing of
for providing care to the ageing population and those patient, caregiver and provider experiences, would allow
experiencing a delayed discharge.2 Walker outlined for a deeper exploration and understanding of success
recommendations for improving primary care, the care from the perspectives of different stakeholders involved
continuum and senior friendly acute care, responding to in the initiative.105–107 Experiential evidence on whether
special needs populations (eg, persons with mental health an intervention is working is required. As noted in our
concerns, addiction and neurological conditions, on dial- review, a tool developed to better understand delayed
ysis or ventilators), and implementing an ‘Assess and discharge was deemed irrelevant by care providers who
Restore’ model (a programme to help patients maintain felt that the tool captured the wrong information.50 There-
or regain functional independence, transition to home fore, capturing providers’ experiences and perspectives
and remain in the community for as long as possible). are essential in understanding effectiveness of strategies
The NHS improvement (UK) also released a guide as well as uptake. Most articles included in this scoping
in 2019 on reducing long hospital stays.104 This guide review used a quantitative study design, with limited arti-
contained several recommendations for tackling delayed cles using mixed methods or qualitative approaches; thus
discharges including: a patient flow bundle (a tool to highlighting a key focus for future research.
reduce delays for patients on inpatient wards), Red2Green The majority of initiatives had an intervention or
Days (a visual tool to reduce unnecessary waiting by follow-up period of 1 year, but this ranged from 4 months
patients by supporting the rounding process), long- to 3 years. Based on the limited number initiatives with a
stay patient reviews (weekly reviews of long-stay patients follow-up period of longer than 1 year (n=8), there is a
(>20 days), to help tackle obstacles that are delaying need for more formal evaluations with longer follow-up
discharge) and multiagency discharge events (review of periods to measure the sustainability of initiatives over
individual patient journeys by bringing together senior time. For example, Shelton et al’s Integrated Sustain-
staff from the local health and social care system). ability Framework consists of five categories of factors
associated with the sustainability of interventions across
different contexts and settings: outer context (eg, poli-
DISCUSSION cies, leadership, funding), inner context (eg, culture,
The purpose of this scoping review was to identify best mission, funding), intervention characteristics (eg,
practices for reducing delayed discharges, examine the cost, adaptability, benefit), processes (eg, partnership,
characteristics of identified initiatives and develop recom- training/support, planning, capacity building) and
mendations for future work. Based on the 66 included implementer and population characteristics (eg, imple-
articles, our findings showed that: (1) initiatives are mentation skills/expertise, attitudes/motivation).108

Open access
Shelton et al recommended prospective, multi-level and strategy (how strategies were implemented, over what
mixed methods study designs for studying the impact time period, how implementation challenges were dealt
and sustainability of interventions. Overall, the initiatives with), setting (where was it implemented) and popu-
included in this scoping review had positive short-term lation characteristics (who was it implemented for).
impacts, but it is unclear if these outcomes are main- The implementation of initiatives can be impacted by
tained over time. This emphasises the need to design and differences in healthcare system structure and funding.
implement interventions with sustainability in mind. Further, this contextual information is essential for both
The majority of categories of initiatives resulted in posi- understanding outcomes, scaling-up and sustainability of
tive outcomes; however, initiatives classified as practice interventions because it is not only important to know if
change had the most mixed outcomes (positive, negative the intervention was effective, but also for whom and in
and no change). Practice changes often require a greater what context it was effective.110 111
number of resources and are more complex to implement Finally, this review highlighted a lack of consistency
than static solutions (ie, hosting daily rounds, developing in how delayed discharge was defined, both within and
a framework, etc). A recent systematic review (2018) across countries. While there was one definition that was
conducted by Geerligs et al identified implementation used more frequently (a patient was identified as medi-
barriers and facilitators of patient- focused, in-hospital cally ready/fit for discharge, but remained in hospital),
interventions,109 highlighting the complex interplay of there can be different interpretations of when a patient
factors that can impact implementation. Three domains, is considered ‘medically fit’ and who makes this deci-
with the potential to impact the implementation process, sion. Inconsistent definitions can lead to variations in the
were identified: system (environmental context, culture, reported rates of delayed discharge, which can further
communication processes and external requirements), impact the perceived applicability and effectiveness of an
staff (commitment and attitudes, understanding and intervention. Our finding was echoed in a narrative review
awareness, role identity and skills, ability and confidence) conducted by Glasby et al, who further explained the
and intervention (ease of integration, face validity, safety challenges differing definitions create when attempting
and legality and supportive components). Thus, it is to compare findings.112 In order to mitigate these chal-
important for interventions to be nimble and adaptable lenges, it is critical to be more consistent around how
to support the changing need of patients, caregivers, delayed discharges are defined.
providers, organisations and policy contexts over time.
It was also unclear if some initiatives moved prob- Future work
lems from one sector to another. For example, adding From this review, we have identified areas for future
more intermediate care beds may alleviate pressures in research. First, patient, family and provider needs and
acute care in the short-term but eventually also be at full experiences should be explored during the development
capacity if community resources are not available. The and implementation of initiatives aimed at improving
7-
day hospital discharge initiative highlighted in this delayed discharges. Patient and family engagement is both
review, improved hospital throughput but had no impact important and recommended by healthcare and govern-
on re-admissions,70 suggesting that thinking beyond one ment organisations; however, they are often excluded
sector is required. It is encouraging that most practice in the development and write-up of best practice guide-
change initiatives resulted in improved outcomes, but lines.113 Second, evaluation studies that track outcomes
more clarity is needed to understand what the trade-offs over a longer period of time should be conducted to
were, as well as how to scale-up the successful initiatives. study the sustainability of initiatives over time, how they
Health systems also need to consider their broader are adapted (developmental evaluations), as well as
goals around delayed hospital discharge—should it only their impact on other sectors (eg, primary and commu-
be about reducing delays or should we place an equal nity care). Third, initiatives should be implemented and
focus on optimising patient and caregiver experiences integrated across sectors (hospital, primary care and
and outcomes? The health system context, including the home and community care) to help get at the root of the
funding environment, will ultimately shape what inter- problem and ensure the implementation of an initiative in
ventions get implemented and how they are sustained one setting does not simply shift the problem to another.
over time. Some interventions may be considered low Fourth, a review should be conducted to assess the state
value in some countries and contexts and high value of knowledge around initiatives that are more upstream
in others. Additionally, certain initiatives may be more in nature (eg, hospital admission avoidance, emergency
effective in different environments, as variations in the department diversion and delivery models that proactively
number of hospital and long-term care beds per capita, address the health and social care needs of individuals in
infrastructure financing and degree of integration across community settings). Finally, there is an opportunity for
sectors may impact the outcomes of an initiative. Future future research to consider a realist review of the liter-
research needs to better understand why some strategies ature on delayed hospital discharge to understand the
may thrive in some environments and not others. context, mechanisms of impact, outcomes and theories
Another key finding identified in the scoping review was of change, given that addressing a delayed discharge is
the lack of information and details on the implementation a complex problem. As a first step, we sought to include

Open access
interventions that included hospitals, and this revealed a hospitals including communication huddles, nurse- led
single sector and reactive approach to addressing delayed discharges, home first programmes and building more
discharge. infrastructure had positive short- term impacts. Many
initiatives that led to positive outcomes were implemented
Limitations by a multidisciplinary team and included a number of
There are a few limitations of this review that should components (eg, monthly reports and education). The
be noted. It is possible that some relevant articles were success of these initiatives is based on a service-led defini-
missed because the search was limited from 1 January tion of success (effective use of hospital resources), rather
2004 and 16 August 2019 and conducted in English. Our than success from the patient and family perspective. This
search strategy was comprehensive and we conducted an highlights the need to shift to a more patient-centred
in-depth search of grey literature to minimise the poten- approach that focuses on improving outcomes and expe-
tial of missed articles. While we did not limit the inclusion riences, rather than system and hospital outcomes (ie,
of articles to the English language, our search strategy was length of stay and hospital occupancy) alone. Despite
in English, so there is a possibility that articles published the number of unique initiatives aimed at addressing
in different languages were not identified. We excluded delayed discharges, current strategies may not be getting
studies that changed the threshold/timing of discharge at the root of the problem (initiatives/intervention prior
(early discharge), as they often focused on cost-savings. to hospital admission) and there is a need for solutions
We acknowledge that some of these initiatives may have to this problem that have a long-term and sustainable
transferable lessons to address discharge delays, and impact.
thus, note their exclusion as a potential limitation of
this review. Although it is not a requirement for scoping Author affiliations
reviews,36 the interventions in this review were not criti-
1
Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
2
cally appraised, and thus, we cannot make recommenda- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
3
Rehabiliation Sciences Institute, University of Toronto, Toronto, Ontario, Canada
tions on which interventions should be scaled up. Given 4
Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public
concerns with regression toward the mean, especially for Health, University of Toronto, Toronto, Ontario, Canada
quality improvement projects, any positive results need to 5
Quality Division, Ontario Health, Toronto, Ontario, Canada
6
be interpreted with caution. Health systems are complex, Centre for Health Services and Policy Research, School of Population and Public
evolving environments, where various iterations of strat- Health, University of British Columbia, Vancouver, British Columbia, Canada
7
School of Social Policy, University of Birmingham, Edgbaston, Birmingham, UK
egies are regularly implemented, but not necessarily 8
Department of Family and Community Medicine, University of Toronto, Toronto,
formally reported or published. Future work by our team Ontario, Canada
will include a process evaluation on how strategies are 9
MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, Ontario,
actually implemented in different health system contexts, Canada
as well as why they work or do not work.
Twitter Kristina Marie Kokorelias @kmkokorelias
Ethical considerations Acknowledgements The authors would like to thank the University of Toronto
There are a few ethical concerns associated with scoping librarian for their contribution to the search strategy, as well as Juliane Koropeski
(JK) and Maliha Asif (MA) for their help screening articles. We would like to thank
reviews to be noted. These concerns include authorship, the involvement of our stakeholders who provided feedback on our search terms
transparency and plagiarism. All authors met the Inter- and sent us grey literature. Lastly, we would like to thank our Alternate Level of
national Committee of Medical Journal Editors’ recom- Care Advisory Council and Ida McLaughlin (chair of council) for their continual
mended criteria for authorship and author order was support and feedback on this programme of work.
based on overall contribution to the review. We clearly Contributors KK, SJTG, JS, JG and TK were responsible for the conception and
outlined our methods at each stage of the scoping review design of the study, as well as acquisition of funding for the study. LC, SJTG, KMK
and KK led the screening of articles and the analysis and interpretation of data, but
to ensure transparency and replicability. We also acknowl- all authors contributed to the analysis and interpretation. Drafts of the manuscript
edged individuals who contributed to the review, but who were reviewed and revised by all authors. All of the authors read and approved the
did not warrant authorship. Lastly, when reporting the final manuscript.
results of individual studies, we wrote them in our own Funding This work was supported by the Canadian Institutes of Health Research-
words and cited appropriately to avoid plagiarism. Transitions in Care Strategic Funding Initiative on Best and Wise Practices (Grant
#163064). KK holds the Dr Mathias Gysler Research Chair in Patient and Family
Centred Care. SJTG and TK are funded by the Canadian Institutes of Health
Research Embedded Scientist Salary Award on Transitions in Care working with
CONCLUSIONS Ontario Health (Quality); the award also supported staff to assist with screening.
This scoping review identified a variety of initiatives Competing interests None declared.
addressing delayed discharges across five categories: infor- Patient consent for publication Not required.
mation sharing, tools and guidelines, practice changes, Provenance and peer review Not commissioned; externally peer reviewed.
infrastructure and finance and other. The majority of
Data availability statement All data relevant to the study are included in the
initiatives were focused on practice changes and many article or uploaded as online supplemental information.
incorporated more than one category. Initiatives were Supplemental material This content has been supplied by the author(s). It has
often implemented in a single sector, rather than across not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
sectors. It appears that many strategies implemented in peer-reviewed. Any opinions or recommendations discussed are solely those

Open access
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and 20 Landeiro F, Leal J, Gray AM. The impact of social isolation on
responsibility arising from any reliance placed on the content. Where the content delayed Hospital discharges of older hip fracture patients and
includes any translated material, BMJ does not warrant the accuracy and reliability associated costs. Osteoporos Int 2016;27:737–45.
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Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which 23 Anderson ME, Glasheen JJ, Anoff D, et al. Understanding predictors
of prolonged hospitalizations among general medicine patients: a
permits others to distribute, remix, adapt, build upon this work non-commercially,
guide and preliminary analysis. J Hosp Med 2015;10:623–6.
and license their derivative works on different terms, provided the original work is 24 Hendy P, Patel JH, Kordbacheh T, et al. In-depth analysis of delays
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Lauren Cadel http://orcid.org/0000-0001-6925-8163 maintenance care in a tertiary hospital general medicine service.
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Open access Original research

Initiatives for improving delayed

To cite: Cadel L, Guilcher SJT, ABSTRACT

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291 1

2 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

reviewed at the full-­text level. Thirty full-­text articles were

Stage 4: charting the data

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291 3

Table 1 Categories, descriptions and examples of initiative categorisation

4 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

by prolonged hospitalisation programme and integrated, client-­centred and

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

in a general paediatric inpatient unit observational study readmission rates

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

review populations by reducing health and

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

intermediate care services, adopting a home

screening for frailty, using transitional and

identifying estimated date of discharge,

Figure 2 Categories of initiatives for improving delayed

(visual displays) were used to share information with the

multidisciplinary project team on issues affecting length

(nursing support to prevent deterioration) and commu-

nity services (email updates and involvement of care

tion though in-­ person communication; however, some

used technology. Caminiti et al used technology-­assisted

as having a delayed discharge. Profiles for each physician

Home First – 10 actions to transform discharge

(containing length of stay, number of patients discharged

that month). All information sharing initiatives resulted

Tools and guidelines

The tools and guidelines category included initiatives

tools, guidelines and models to inform practice.47–50 54–67

tool and guideline initiatives. A promising initiative

within this category included the ALC Avoidance Frame-

work, developed by Burr and colleagues, with the goal

rates.56 67 This framework contains 12 leading practices,

with specific strategies for organisational assessment.

Some of the leading practices include: providing patients

and substitute decision makers with an estimated date

22 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291 23

24 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291 25

26 Cadel L, et al. BMJ Open 2021;11:e044291. doi:10.1136/bmjopen-2020-044291

Open access Original research

reviewed at the full-text level. Thirty full-text articles were

by prolonged hospitalisation programme and integrated, client-centred and

tion though in- person communication; however, some

used technology. Caminiti et al used technology-assisted